Isobel Stapleton

Cyfeiriad Dychwelyd/ Return Address: 
Bwrdd Iechyd Prifysgol 
Cwm Taf Morgannwg 
Pencadlys  
Parc Navigation, 
Abercynon  
CF45 4SN 

Cwm Taf Morgannwg 
University Health Board  
Headquarters 
Navigation Park 
Abercynon 
CF45 4SN 

Ffôn/Tel: 

Eich cyf/Your Ref: 
Ein cyf/Our Ref: 
Ebost Email: 
Dyddiad/Date: 

15 August 2024 

Mr D Regan 
Assistant Coroner 
South Wales Central 
Coroner’s Office 
The Old Courthouse 
Courthouse Street 
Pontypridd 
CF37 1JW 

Dear Mr Regan 

Regulation 28 Report to Prevent Future Deaths 

I  am  writing  in  response  to  the  Regulation  28  Report  issued  to  Cwm  Taf 
Morgannwg University Health Board (CTMUHB) on 28th June 2024 following the 
conclusion of the inquest into the death of Isobel Lilian Stapleton, whilst under 
the  care  of  the  Merthyr  and  Cynon  (M+C)  Crisis  Resolution  Home  Treatment 
Team (CRHTT). 

The Health Board values the opportunity to learn from the tragic events relating 
to Isobel’s  death. The  Regulation  28 report  identified  5  key areas of  concern 
listed below: 

Cadeirydd/Chair: 

 Prif Weithredwr/Chief Executive: 

Croeso i chi gyfathrebu â’r bwrdd iechyd yn y Gymraeg neu'r Saesneg. Byddwn yn ymateb yn yr un iaith a ni fydd hyn yn arwain at oedi. 
You are welcome to correspond with the Health Board in Welsh or English. We will respond accordingly and this will not delay the response. 

https://ctmuhb.nhs.wales  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (1)  Mental  health  practitioners  are  not  easily  able  to  access  all  of  a 
patient's relevant clinical records pending the introduction of a "Once for 
Wales"  solution,  for  which  there 
for 
implementation. 

is  currently  no  timetable 

(2) Mental health practitioners may not be aware of the existence of all 
such records, some of which may be in paper. 

(3) Mental health practitioners in Wales currently have no way easily to 
access NHS England clinical records. 

(4) The inpatient hospital team at the Royal Glamorgan Hospital did and 
does  not  have  access  to  a  clinical  psychologist  to  provide  direct 
assessment and treatment of a patient. 

(5)  The  Home  treatment  team  covering  Merthyr  Tydfil  does  not  have 
access  to  a  clinical  psychologist  to  provide  direct  assessment  and 
treatment of a patient. The waiting list for any necessary psychotherapy 
is months in length. 

This  response  is  limited  to  the  actions  taken  by  CTMUHB  in  relation  to  the 
Coronial concerns, each of which  will be responded to individually in order to 
provide assurance on the improvement actions implemented. 

1.  Mental  health  practitioners  are  not  easily  able  to  access  all  of  a 
patient's relevant clinical records pending the introduction of a "Once 
for  Wales"  solution,  for  which  there  is  currently  no  timetable  for 
implementation 

Firstly, I would like to provide assurance that the Health Board acknowledges 
the  need  to  digitalise  health  records  in  order  to  improve  patient  safety,  data 
accessibility,  and  clinical  decision  making  at  point  of  contact  with  the  people 
who use our mental health services. 

I  can  report  that  the  Health  Board  had  approved  prioritisation  of  the 
implementation  of  the  national  Care  Director  solution  under  the  Welsh 
Community  Care  Information  System  (WCCIS)  programme.  As  a  result, 
throughout Spring and Summer 2023 the Health Board commenced a series of 
workshops and planning exercises, supported by local authority colleagues and 
the national team within Digital Health Care Wales (DHCW). However, during 
this time, significant operational issues with the Care Director system identified 
by  an  early  implementing  neighbouring  Health  Board  raised  questions  about 
future implementation. In addition, we noted that Care Director as a national 
solution will be withdrawn in January 2026, so all organisations are reviewing  

 
 
 
 
 
 
 
 
 
 
 
 
 their  position  on  the  best  way  forward  and  preferred  solution  and  operating 
model.  

The  Health  Board  has  continued  to  work  with  the  National  programme  for 
Connecting Care, with an aim to deliver a fully integrated Mental Health solution 
as a priority. A Business Case was due to be submitted at the end of July 2024  
for an alternative national solution but at the time of writing this response it has 
not been received by Welsh Government. 

As a contingency measure we are also working with colleagues in another Health 
Board  to  accelerate  the  procurement  and  implementation  of  a  Mental  Health 
solution should the Connecting Care business case not be approved in the near 
future.  CTMUHB  are  working  on  a  business  case  for  this  which  will  include 
timescales and deployments plans, it is expected that we will be ready to procure 
in the Autumn of 2024. 

2.Mental health practitioners may not be aware of the existence of all 
such records, some of which may be in paper.  

Within the Health Board the multiple systems of documentation in mental health 
services has been highlighted as a high risk and as such is on the organisational 
risk register which is reported to Board.  

As a mitigation for the multiple record system that are still in place across the 
Mental  Health  and  Learning  Disability  (MHLD)  Care  Group  the  Health  Board 
developed  a  Clinical  Information  Access  and  Recording    Matrix  (CIARM)  in 
August 2023 for clinical team/staff access for all systems across the MHLD Care 
Group. This  informs  all  clinical  staff of  how to  access patient  clinical  risk  and 
discharge planning information both in and out of hours and is the primary tool 
by which the MHLD Care Group mitigates the potential risks inherent with our 
present multiple systems.  

The  CIARM  covers  all  clinical  areas  and  teams  and  is  accessible  through  the 
Health  Board  SharePoint  (CTMUHB  intranet)  system  for  ease  of  access  from 
every CTM desktop. A simple Standard Operational Procedure accompanies the 
matrix.   Local copies have been copied, laminated and distributed to all inpatient 
units  and  unscheduled  mental  health  assessment  teams  and  strict  version 
control is maintained by the MHLD Digital Transformation Project Lead with any 
updates shared with all staff. 

With CIARM now in place practitioners report that patient information  is shared 
more effectively between staff across multiple sites (in and outside of normal 
working hours) which allows more time to be spent on patient care, and that  
clinical  staff  now  have  the  right  information  and  the  right  time  to  inform 
Multidisciplinary decision making. The MHLD Care Group has finalised a range 
of  routine  audits  of  documentation,  information  sharing  and  communication 

 
 
 
 
 
 
 
 
 
 
 standards that have been digitalised through development of the Health Board  
Audit Management and Tracking (AMaT) platform.    

4.  The  inpatient  hospital  team  at  the  Royal  Glamorgan  Hospital  did 
and does not have access to a clinical psychologist to provide direct 
assessment and treatment of a patient.  

The acute mental health psychological team has been at full establishment since 
June 2024. This consists of a total 4.3 whole time equivalent staff (WTE) across 
CTMUHB acute adult mental health services: 

 

 

 
 

 
 

8c  Consultant  Clinical  Psychologist  0.8wte:  strategic  and  operational 
responsibility for psychological professions pan acute service  
8b  Practitioner  Psychologist  0.8wte:  Ward  14;  Psychiatric  Intensive 
Care Unit (PICU); Bridgend CRHTT 
Band 7 Art psychotherapist 0.6wte ward 14 and PICU 
Band  7  Psychological  Practitioner:  1.0wte  CRHTT  Rhondda  Taf  Ely 
(RTE) 
Band 6 Trainee Clinical Associate Applied Psychologist (CAAP) 0.6wte 
Band 6 Psychological Practitioner: 0.5wte CRHTT M+C 

There  is  no  designated  clinical  psychology  provision  for  the  Royal  Glamorgan 
Hospital  Mental  health  Unit  (RGH  MHU).  In  an  attempt  to  mitigate  this,  the 
following has been put in place: 

  Sessions are provided into RGH MHU from the 8c Consultant Psychologist 

and the RTE band 7 Psychological Practitioner.  

  Skills  development/  emotional  regulation  and  psychoeducation  work  is 
provided  by  undergraduate  students  on  nine-month  clinical  placements 
from  the  University  of  Bath.  This  work  is  closely  supervised  by  the 
Consultant Clinical Psychologist.  

  The  trainee  CAAP  provides  assessment,  formulation  and  CBT-based 
interventions  for  individual  patients  on  the  ward.  However,  the  Trainee 
CAAP has only recently started their training placement (January, 2024) 
so the level of complexity  of input they  are able  to provide is therefore 
limited at this point. 

  As  part  of  the  broader  improvement  work  to  the  inpatient  service, 
workforce development is aimed at upskilling ward staff to be able to offer 
psychologically informed low-level interventions.  

5. The  Home  treatment  team  covering  Merthyr  Tydfil  does  not  have 
access  to  a  clinical  psychologist  to  provide  direct  assessment  and 
list  for  any  necessary 
treatment  of  a  patient.  The  waiting 
psychotherapy is months in length 

Since June  2024,  there  is  a  dedicated  psychological  professional  available for 
direct  assessment  and  treatment  into  all  three  of  the  CRHTTs.  There  is  no 

 
 
 
 
 
 
 
 
 
 waiting list in these services, and the Psychologists and Psychological Therapists 
work closely with the team as soon as a need for input is identified. There has 
been significant investment of resource to address the backlog of people waiting 
for  psychological  therapies  in  both  Primary  and  Secondary  mental  health 
services. This has reduced the number of people waiting over 52 weeks from 
221 in May 2023 to 109 in May 2024.  

In  addition,  people  on  the  waiting  list  for  psychological  therapies  in  Local 
Primary Mental Health Support Services receive a contact phone call after two 
weeks  and  6  months  of  waiting.  The  service  uses  CORE-10,  a  standardised 
assessment  of common presentations of psychological distress to monitor and 
escalate any significant changes in clinical presentation or risk, at both of these 
contact points. 

I hope that this response provides explanation and assurance that CTMUHB are 
committed to fully address the concerns in the Regulation 28 Report relating to 
Isobel Lilian Stapleton’s death.  

Please do not hesitate to contact 
, Medical Director if you would 
like further assurances or if you require a meeting to discuss any arising areas  

Yours sincerely 

Prif Weithredwr/Chief Executive

Y Gweinidog Iechyd Meddwl a’r Blynyddoedd Cynnar 
Minister for Mental Health & Early Years 

Eich cyf/Your ref: 
Ein cyf/Our ref: 

David Regan 
Assistant Coroner for South Wales Central Coroner Area 
Coroner’s Office 
The Old Courthouse Street 
Pontypridd 
CF37 1JW 

 14 August 2024  

Dear David Regan, 

Thank you for your letter and the accompanying Regulation 28 report following the 
investigation into the death of Isobel Lilian Stapleton. My immediate thoughts are with Ms 
Stapleton’s family and friends.  

I am committed to ensuring that our services continue to learn from incidents like this, with 
the view to delivering safe and person-centred services, in line with the Health and Social 
Care (Quality and Engagement) (Wales) Act 2020 and our Health and Quality Care 
Standards. 

In relation to the first three matters of concern in your report, I wish to highlight that a 
business case is being developed by Digital Health and Care Wales for the introduction and 
deployment of mental health systems across health boards in NHS Wales.  Once a 
timetable for deployment has been agreed, this will be communicated. However, it is 
anticipated that this will be a phased approach over a number of years. This will align work 
to improve digital and data service provision in mental health. It will be based on the 
principle of parity with physical health and will deliver on key areas including electronic 
records, data sharing, use of digital across services, and improved mental health data. 
Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the 
implementation of electronic patient records for mental health, ahead of the all-Wales 
system.  

We have also provided dedicated support in the NHS Wales Executive to support health 
boards to improve the quality and safety of mental health services. This includes through a 
Strategic Mental Health Programme and a Mental Health Patient Safety Programme. A key 
focus of this work will be to improve discharge arrangements and to drive improvements in 
the quality of care and treatment planning. I am committed to ensuring a person-centred 

Bae Caerdydd • Cardiff Bay 
Caerdydd • Cardiff 
CF99 1SN 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
gohebu yn Gymraeg yn arwain at oedi.  

We welcome receiving correspondence in Welsh.  Any correspondence received in Welsh will be answered in Welsh and corresponding 
in Welsh will not lead to a delay in responding.   

 
 
 
 
 
 
 
 
 
 
 
 
 approach to improve services – this includes with families and unpaid carers who play a 
crucial role in supporting people who are living with poor mental health. Care and treatment 
planning also enables us to capture this effectively, allowing us to be truly person-centred 
and to provide a focus on being “recovery-focused”. This approach, and our broader cross-
Government work that we are taking, is out in our draft Mental Health and Well-being 
Strategy, which we consulted on recently. 

Alongside this, the draft Suicide and Self-harm Prevention Strategy includes commitments 
to deliver rapid and impactful prevention, intervention, and support to those in society who 
are the most vulnerable to suicide and self-harm through the settings with which they are 
most engaged. This includes those in contact with mental health services. It also includes 
an objective to increase skills, awareness, knowledge and understanding of suicide and 
self-harm amongst the public, professionals and agencies who may come into contact with 
those at risk of suicide and self-harm.    

In relation to matters of concern 4 and 5, I have written to Cwm Taf Morgannwg University 
Health Board to seek assurances in relation to in-patient access to clinical psychology, and 
support and treatment in the community. 

I hope this provides you with the required assurances that we have carefully considered 
your report – and that I will continue to focus on delivering improvements to mental health  
services, and the approach we take to suicide prevention.  

Yours sincerely, 

Y Gweinidog Iechyd Meddwl a’r Blynyddoedd Cynnar  
Minister for Mental Health & Early Years